Lateral ankle fusion plate system and jig, and method for use therewith

ABSTRACT

The invention comprises a lateral ankle fusion plate, a jig for use with the fusion plate and a method for ankle fusion of the joints between the tibia, the talus, and the calcaneus. In addition, a separate fusion screw from posterior to anterior through the calcaneal tuberosity into the distal tibia is useful and can be placed using the targeting jig of the invention. The plate includes a C-shaped stirrup portion that wraps the bottom of the calcaneus and is provided with a screw hole for a T-T-C-fusion screw. A C-shaped targeting jig is provided that interfaces with the plate to allow for placement of the calcaneal screw and has an additional attachment for placement of the independent fusion screw so as to avoid impingement with the plate, and plate screws. The invention also relates to a method of surgery that incorporates the use of the plate, the jig and the tibial/talar/calcaneal fusion screw for an arthrodesis of the ankle joint.

FIELD OF THE INVENTION

The present disclosure relates to an invention which involves an anklefusion plate system, a jig for use with the fusion plate system and amethod for ankle fusion, i.e. arthrodesis, where the joints between thetibia, the talus, and the calcaneus of a human patient can beimmobilized using a lateral implant alone, or in combination with aseparate fusion screw from posterior to anterior through the calcanealtuberosity into the distal tibia. The plate includes a C-shaped stirrupportion that wraps the bottom of the calcaneus and is provided with ascrew hole for the placement of a relatively vertical screw (i.e.,relative to the lower leg, i.e., in the sagittal plane from inferior tosuperior) through the articular capsule of the talocalcaneal joint andthe tibiotalar joint and which secures the calcaneus, the talus and thetibia together. An independent 50-100 mm fusion screw can be used withthe lateral plate to augment the immobilization by multiplanar fixation.This screw is placed from the posterior calcaneus at a superiorlyextending angle through the talus toward the anterior distal tibia. AC-shaped targeting jig is provided that interfaces with the plate toallow for placement of the calcaneal screw and pivots for placement ofthe fusion screw so as to avoid impingement with the plate, and platescrews. The invention also relates to a method of surgery thatincorporates the use of the plate, the jig and thetibial/talar/calcaneal fusion screw for an arthrodesis of the anklejoint.

BACKGROUND OF THE INVENTION

Despite the importance of a fully functional ankle joint for movementand balance, there are instances in which the pain that can be generatedby certain pathologies justify fusion in order to alleviate on-goingpain. It is sometimes necessary or desirable to cause fusion orarthrodesis of the primary bones that form the ankle joint, for example,in the case of osteoarthritis, post-traumatic osteoarthritis, anklearthritis or after failure of total ankle replacement. In this instancegiven the role of the ankle in allowing for balance and movement, giventhe high loads to which the ankle joint is subjected, and given therelative lack of soft tissue to cover an implant, it is particularlyimportant that the procedure result in a highly precise placement of theimplant and fasteners, as well as a precise and secure jointimmobilization.

Prior art devices for use in arthrodesis include wires, screws, platesand intramedullary devices. While such devices exist, each is lacking inproviding one or more of the desired precision, stability, fixation, orrelative ease of implantation that an orthopedic surgeon desires forsuch a device.

Thus, it is an object of the present invention is to provide an anklefusion system and surgical method for implanting an implant in a humanankle, which allows for fusion of the distal end of a tibia, the talusand calcaneus (i.e. the “T-T-C” interface) using a lateral incision tothe tibia, talus, fibula and calcaneus region, removing some or all of afibula in the incision area, attaching the implant to the tibia, talusand calcaneus in a generally central area of the lateral ankle so as toencourage the bones to fuse together. The system includes a lateral patehaving a central rail member with fastener holes and preferablyincluding one or more locking holes and/or compression holes. The railmember is planar across its width and includes a slight undulation inthe z dimension along the longitudinal axis to accommodate a generalizedsurface of the distal tibia in the place of the fibula that has beenremoved. The inferior portion of the plate forms a C-shaped stirrupunder the calcaneus and includes at its inferior-most end a screw holefor the placement of a fusion screw, which is advantageously acompression screw of sufficient length to extend through the T-T-Cinterfaces. The invention further includes a jig, which attaches to therail to permit a placement of the T-T-C screw that avoids impingementwith the other plate fasteners, and also that is at the optimal angle toachieve fusion. The fusion is augmented by the use of the separate (i.e.which does not cooperate directly with the plate) fusion screw thatangles up through the calcaneus, talus to the anterior portion of thedistal tibia.

Apart from the calcaneal stirrup segment, the rail member has a firstlateral segment that abuts the calcaneus, a second lateral segment thatabuts the talus, and a third lateral segment that abuts the tibia. Therail member further includes tabs or wing portions on each of thecalcaneal segment, the talar segment, and the tibial segment. Thecalcaneal wing includes a plurality of fastener holes, i.e., preferablya triangular arrangement of three, and a slot for placement wires, suchas k-wires, while a tab extends from the anterior edge of the railmember in the talar segment substantially in opposition to a slightlyposterior talar tab, each of which has a single locking screw hole. Theanterior talar wing also has a slot for a guide wire. The tibial segmenthas stepped tabs, which wrap around the tibia on each of the anteriorand posterior sides with each tab including a single locking screw hole.This segment also includes compression slots below and above the steppedtabs. The talar segment of the plate also includes a central lockinghole that can be used for a screw as well as to position and fasten thetargeting jig relative to the plate.

The calcaneal jig in accordance with the present invention has a largeC-shaped end, which can be pivoted in relation to the central talarhole, and having a drill guide to position a second fusion screw in aposterior portion of the calcaneus. Examples of the conditions for whichthe present invention are useful include arthritis with or withoutassociated deformity of the ankle and subtalar joint, rheumatologicarthritis and deformity, severe ankle and subtalar arthrosis, talarcollapse, avascular necrosis of the talus, hindfoot deformity, stage 4flatfoot and/or Charcot neuroarthropathy and/or deformity. The inventioncan be used for both a tibiotalocalcaneal and a tibiocalcaneal (TC)arthrodesis where a partial or total talectomy is necessary.

SUMMARY OF THE INVENTION

An object of the present disclosure is therefore to provide a system forankle fusion which improves upon the short-comings of the prior art andto provide novel systems and methods for immobilizing the joints betweenthe tibia, talus and the calcaneus of a human patient that makes itpossible to perform arthrodesis under good operating conditions whilealso making it possible to obtain bone fusion that is particularlystable, strong, precise, and comfortable for the patient.

Another object of the present disclosure is to provide novel systems andmethods for immobilizing the joints between the tibia, talus, and thecalcaneus of a human patient that is particularly successful under allconditions of bone quality or pathology.

Another object of the present disclosure is to provide novel systems andmethods for immobilizing the joints between the tibia, talus, and thecalcaneus of a human patient that is relatively easy to implant, thatavoids the most congested areas of ligament and tendon involvement, andthat result in reliable bone fusion.

The objects assigned to the present disclosure are achieved by systemsand methods as described herein for immobilizing the joint between thetibia and the talus of a human patient. The system and method of thepresent disclosure comprise a lateral T-T-C fusion plate system thatincludes a rail member having a tibial segment, a talar segment and acalcaneal segment which extends into a C-shaped segment that cradles theinferior portion of the calcaneus, and cooperates with a compressionscrew that extends upwardly through the calcaneus, the talus and intothe tibia. A C-shaped targeting jig is provided that facilitates theplacement of the calcaneal fusion screw, and which can be pivoted toallow an independent posterior screw to be angled in the T-T-C joint soas to avoid impingement with the fastener screws.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 is a front view of a left T-T-C fusion plate of the presentinvention;

FIG. 2 is a cross section of the plate of FIG. 1 taken along line 2-2;

FIG. 3 is a side view of the plate of FIG. 1 taken from the posteriorside;

FIG. 4 is an end view of the plate of FIG. 1 taken from the proximal end(from an anatomical perspective);

FIG. 5 is an end perspective view of the plate of FIG. 1 taken from theproximal end;

FIG. 6 is a lateral view of the plate of FIG. 1 with screws in positionon an ankle;

FIG. 7 is an anterior view of the plate of FIG. 1 with screws inposition on an ankle;

FIG. 8 is a lateral view of the plate of FIG. 1 in position on an ankle,and including the jig for placement of the calcaneal screw through thescrew hole in the calcaneal stirrup segment of the plate;

FIG. 9 is an anterior view of the plate of FIG. 1 in position on anankle and including the jig for placement of a separate fusion screwthrough the T-T-C joint;

FIG. 10 is a side perspective of the targeting jig from FIG. 8;

FIG. 11 is a side view of the targeting jig from FIG. 8 with an explodedview of the pivoting screw, fusion screw axis and pilot drill guide;

FIG. 12 is a side perspective of the targeting jig showing the placementof the fusion screws;

FIG. 13 is a lateral (front) view of the plate and screws in position onan ankle;

FIG. 14 is an illustration of the first step in use of the assembly ofthe parts of a drill guide in accordance with the present invention;

FIG. 15 is an illustration of the assembly of FIG. 14;

FIG. 16 is an illustration of the assembly of the drill guide with thebone plate in accordance with the present invention;

FIG. 17 is illustration of the drill guide in position on the bone platein accordance with the present invention;

FIG. 18 is an illustration of the drill guide and bone plate with guidewires in position;

FIG. 19 is an illustration of the assembly of FIG. 17 used for theinsertion of a fusion screw through the distal end of the plate;

FIG. 20 is an illustration of showing the addition of a further drillguide for an independent fusion screw;

FIG. 21 is an illustration of the assembly of FIG. 18 showing anadditional guide wire for the fusion screw;

FIG. 22 is a posterior view showing the placement of the fusion screw inaccordance with the invention;

FIG. 23 is a posterior view of the assembly of the plate and fusionscrews in accordance with the present invention; and

FIG. 24 a side and posterior view of the assembly of the plate andfusion screws in accordance with the present invention.

DETAILED DESCRIPTION OF THE INVENTION

FIG. 1 illustrates a side view of a lateral ankle fusion plate 10 inaccordance with the present invention. The plate 10 has a central railmember 12 with a first segment 14 that abuts the calcaneus. This segmenthas a C-shaped portion or stirrup 16 (i.e. along the longitudinal axis)that wraps under the inferior surface of the calcaneus. The curve is acompound curve that forms about 70°+/−10°, or more preferably 5°, of acircle and having a radius of from about 0.74 to about 0.84 inch +/−0.1inch such that the terminal screw hole 18 in the calcaneal position isabout 1.8 inch +/−0.25 inch from the posterior screw hole in the talarsegment. The plate has a length from the axis of the central screw holeof the talar segment in the tibial terminus of about 3 inches +/−0.25inch.

The central axis 18′ of the screw hole 18 forms an angle of from about30° to about 60°, and preferably at about 40° to about 50°, and mostpreferably at about 42° to about 47° to a medial line in that second ortalar segment of the plate (shown in FIG. 2). This hole receives acompression screw 20 that is from about 50 to about 100 mm andpreferably from about 70 to about 90 mm long. Advantageously, this is alag screw, or a compression screw having a distal set of threads 22abutting a non-threaded region 23 and a head 24 that interfaces with theplate 10 to avow the screw 20 to draw the plate into the bone and todraw the bones of the T-T-C together. In addition, it is preferable thatthis screw includes a cannulation (not shown).

The first longitudinal or calcaneal segment 14 also includes a firstlaterally oriented (i.e., relative to the body) section 28, which has aposteriorly placed locking hole 29 and a posterior calcaneal wing 30.This wing includes three locking holes wherein an intermediate hole 34opposes the locking hole 29 and locking holes 32 and 36 are locatedcloser to the longitudinal axis of the rail portion of the plate, butare respectively more inferior and superior to the intermediate lockinghole 34. Specifically, the locking holes of the present invention areinternally threaded and correspond to the threads which are external tothe head of a locking screw 31 used within the locking holes of theinvention. Of course, it should be understood that other means oflocking may be used, such as variable locking assemblies. The lockingholes are also shown as including a triad of channels 33 which providefor the seating of a drill guide to permit the placement of a pilot holethat will accommodate the locking screw that is placed through thecorresponding hole

The second longitudinal or talar segment 40 includes a central lockinghole 42 and an anterior tab or wing 44 and a posterior tab 46 thatrespectively extend anteriorly and posteriorly from the side of the railportion. The posterior tab 46 includes a single locking hole 48, whilethe anterior tab includes a locking hole 47 and a slot 49 for a guidewire where the locking hole is aligned along the longitudinal axis ofthe plate with the central locking hole 42.

The third longitudinal or tibial segment of the plate 60, includes afirst and a second compression slot 61,62 each having lateral edges 63that define a shoulder which angles toward the bone facing side of theplate in the direction of the calcaneal segment. The tibial segment alsoincludes two pairs of tabs 64,66 and 65,67 having respective lockingholes 68 and located on each of the anterior and the posterior sides ofthe plates where the tabs alternate in position along the length of therail beginning with a first tab on the posterior side and ending with ananterior tab on the proximal (i.e., at the tibial) end of the plate.Further, these tabs in the tibial segment are angled away from the railmember so as to wrap the tibia. Thus, these tabs extend at a smallerangle than the tabs of the first and second longitudinal segments whichmay be substantially co-planar with the rail portion of the plate towhich they are attached. The second compression slot 62 is located inthe proximal end of the plate 10. This section also includes slots 69for guide wires.

The rail member 12 is planar across its width and includes a slightundulation in the z dimension along the longitudinal axis to accommodatea generalized surface of the distal tibia in the place of the fibulathat has been removed. The inferior portion of the plate forms aC-shaped stirrup under the calcaneus and includes at its inferior mostend, a hole 18 for a T-T-C fusion screw 20. This screw 20 can be placedusing the drill guide section 78 of a C-shaped jig member 80 having abody 82, which attaches by threading an attachment member 84 into thecentral locking screw hole 42 of the talar segment 40 of the rail 12 topermit a placement of the T-T-C fusion screw 20 that avoids impingementwith the other plate fasteners, and also that is at the optimal angle toachieve fusion. As is illustrated in FIG. 11, once a pilot hole isdrilled for the fusion screw, the screw can be implanted with the jig inplace through an opening 86 in the end of the jig. In addition the jighas an arm 90 with a guide 92 having a hole 91 for a pilot drill andjournaled in a left or a right hole 93 in the body 82 of the jig todefine an optimal angle 92 for a separate fusion screw 90. The fusion isaugmented by the separate (i.e. which is does not cooperate directlywith the plate) fusion screw 90 that angles up through the calcaneus,talus to the medial portion of the tibia superior to the medialmalleolus. This separate screw 98 is of a similar length as the screw20, i.e., from about 50 to about 100 mm long, and preferably from about65 to about 80 mm long, and is a compression screw which mayadvantageously be threaded along a distal portion of the screw, andlacking threads in an area adjacent the head of the screw.

A surgical technique in accordance with the invention is described asfollows:

Surgical Approach

A lateral transfibular approach to the ankle and hindfoot is used forthe arthrodesis and correction of deformity. Although this distalfibulectomy may slightly devascularize the lateral ankle, this techniquecalls for a fibulectomy for exposure and plate application. Thisapproach is particularly useful in the setting of severe deformity ineither the sagittal or coronal plane or both.

Exposure

The incision is made vertically, directly over the fibula, extendingdown distally over the sinus tarsi toward the inferior aspect of thecalcaneus. The sural nerve must be identified and then retractedinferiorly and posteriorly with the peroneal tendons. It may benecessary to retract the nerve and tendons anteriorly depending on thesoft tissue, scarring and deformity. In some cases it is acceptable tocut the peroneal tendons, particularly where they are already torn, acommon finding with a chronic varus hindfoot and ankle deformity.

Once the peroneal tendons are retracted posteriorly, the calcaneofibularand anterior talofibular ligaments are cut exposing the entire distalfibula. A fibulectomy is now performed. It is ideal to use the fibulafor bone graft, and this can either be morcellized following anosteotomy with a saw, or removed by harvesting the entire fibula. If adistal fibulectomy is performed, harvesting the entire distal 4 cm witha small acetabular reamer can be done. The reamer is applied withpressure to the fibula, and is used to completely denude and decorticatethe bone leaving a shell of the inner cortex behind yielding copiouscancellous graft. For application of the plate, it is necessary toremove the distal 8 cm of the fibula, and following use of the reamer,the remaining fibula is cut more proximally with a saw and discarded.

The lateral aspect of the calcaneus must be exposed to visualize theplantar lateral margin of the calcaneus for apposition of the plate. Theapproach to preparation of the joint surfaces depends on the need forpreservation of the anatomy and the presence of deformity. If there isminimal deformity present, then it is preferable to use a chisel tothoroughly denude the ankle and subtalar joints. One should be carefulnot to remove excess bone laterally from either joint since this willtilt the arthrodesis into valgus. Nevertheless, maintaining the contourof both the ankle and subtalar joint is an option. If deformity ispresent, the joint surfaces can be prepared by making flat cuts with asaw.

A wide fan shaped saw blade is used protecting the soft tissue on theposterior and anterior ankle with malleable retractors. The saw isoriented perpendicular to the tibial shaft and the tibial plafond cut,removing about 2 mm in the center of the joint increasing to about 5 mmanteriorly and 7 mm posteriorly depending on the presence of osteophytesin the anterior and posterior ankle. Then while holding the ankle inneutral dorsiflexion and 5-7 degrees of valgus, a parallel flat cut ismade on the dome of the talus removing approximately 5 mm of bone.

Depending on the ability to obtain a plantigrade foot and the ankle in aneutral position, the medial malleolus may be cut obliquely through aseparate incision on the medial ankle. This cut is made obliquely toexit at the level of the tibial plafond. This osteotomy will permit easytranslation of the talus under the tibia in any direction to facilitatedeformity correction.

Once the foot is in a neutral position under the tibia, the neutralposition should be verified under fluoroscopy and provisionallymaintained by two crossing guide wires. The lateral flare of the distaltibia will require ostectomy with a chisel or osteotomy to allow theplate to sit flush on the bone surface.

Surgical Technique

Step 1: Assemble the primary targeting guide by inserting the K-wireguide insert into the distal head of the guide as shown in FIG. 14 andas assembled in FIG. 15.

Step 2: Attach the lateral ankle fusion plate (depending on theoperative side) by threading the insert into the central locking hole onthe plate as shown in FIGS. 16 and 17. The guide can be used as a handleto aid in plate placement.

Step 3: Insert the plate deep into the peroneal tendons (the tendons canbe excised if torn) in order to avoid compromising either skin closureor ultimate peroneal function. The distal portion of the jig should sitoutside of the incision and wrap under the inferior aspect of thecalcaneus. This guide will later facilitate the insertion of a 7.0 mmscrew from the calcaneus into the tibia.

Step 4: The plate can now be provisionally fixed by a combination ofk-wires and olive wires. When placing k-wires within the k-wire slots,place them in the most proximal portion of the slot. This will allow forcompression in subsequent steps as the relative motion of the plate willallow translation from distal to proximal during compression.

Step 5: insert a 2.3 mm k-wire through one of the holes in the K-wireguide Insert as shown in FIG. 18. The angle of the k-wire will depend onthe height of the talus but should be inserted so as to maximize thecortical capture of the distal tibia. The targeting guide hasgraduations of +0°, +5° and +10° (corresponding to relative angles of23°, 18° and 13° between the k-wire and the plate). Select the anglethat best and most accurately captures the distal medial tibia andconfirm under fluoroscopy.

Step 6: Following fluoroscopic verification of the k-wire position,remove the K wire Guide Insert by snapping it out of the primarytargeting jig and puffing it over the guide wire. Use a 4.7 mmcannulated drill bit to perforate the calcaneus, talus and the corticaledge of the distal tibia.

Step 7: Measure using the provided depth gauge. Using the appropriatedriver, insert the correct length 7.0 mm short thread screw to compressboth the ankle and the subtalar joints as is shown in FIG. 19.

Optional Secondary 7.0 mm Screw Insertion: The Secondary Targeting Guidecan be used if a second 7.0 mm screw is desired. This guide will allowplacement of a 7.0 mm screw through the center of the calcaneus and willprevent collision with the primary screw. The guide is designed tointroduce the guide wire into either the posterior calcaneus or anteriortibia, depending on surgeon preference. The diameter of the secondarytargeting guide rod is the same as the 7.0 mm screws and can be used toapproximate the angle and position of the posterior 7.0 mm screw.

Step 8: Insert the secondary targeting guide through the holecorresponding to the operative side in the primary targeting guide asshown in FIG. 20. Adjust the rod to the desired position and fix inplace by tightening the lock nut using the 7.0 mm driver.

Step 9: Insert a 2.3 mm k-wire through the guide hole in the secondarytargeting guide head as shown in FIG. 21. Drive the wire into thecalcaneus (or tibia) and across the joint line and confirm underfluoroscopy.

Step 10: Following fluoroscopic verification of the position of thek-wire, remove the entire targeting guide assembly and use the 4.7 mmcannulated drill bit to perforate the calcaneus, talus and the anteriorcortical edge of the distal tibia.

Step 11: Measure using the provided depth gauge and insert the correctlength 7.0 mm short thread screw to further compress both the ankle andthe subtalar joints.

Cortical Screw insertion: The remaining locking screw holes may befilled with either Fixed-Angle Locking Screws or Non-Locking Screws asappropriate depending on the need for stability and fixation. Fixedangle drill guides should be used to drill for both screw types.

Step 12: To drill for the remaining screws, use either a drill guidesuch as a fixed drill guide which threads into the locking hole toprovide the proper angle for drilling or a keyed quick insertion drillguide having lobes on the tip of the guide which align with the lobes inthe threaded hole and is pressed into the plate while drilling to ensureproper alignment.

Step 13: Using the 2.4 mm drill bit drill to the desired depth.

Step 14: Measure using the provided depth gage and insert theappropriate length screw using the appropriate driver. FIGS. 22, 23 and24 illustrate the plate, and compression screws placed for ankle fusionin accordance with the method of the present invention.

While in accordance with the patent statutes the best mode and preferredembodiment have been set forth, the scope of the invention is notlimited thereto, but rather by the scope of the attached claims.

1. A fusion implant system comprising a fusion screw and a plate capableof attachment to the lateral section of a tibia and comprising a railmember having a calcaneal segment including a stirrup having a hole thatreceives the fusion screw and a first longitudinal segment that includesa posterior wing, a second longitudinal segment that includes a centralfastener hole and an anterior tab and a posterior tab, and a thirdlongitudinal segment that has at least one fastener hole and at leastone posterior tab and at least one anterior tab.
 2. The fusion implantsystem as set forth in claim 1, further including a targeting jig thatremovably interfaces with the plate in use to permit placement of thefusion screw through the hole in the stirrup of the calcaneal segment.3. The fusion implant system as set forth in claim 2 wherein thetargeting jig further includes an additional jig for placement of asecond fusion screw.
 4. The fusion implant system as set forth in claim3 wherein the rail member further includes a compression slot.
 5. Thefusion implant system as set forth in claim 1 wherein the fusion screwis a compression screw.
 6. The fusion implant system as set forth inclaim 5 wherein the fusion screw is from about 50 to about 100 mm inlength.
 7. The fusion implant system as set forth in claim 2 wherein thejig can be attached to the plate by means of the central fastener hole.8. The fusion implant system as set forth in claim I wherein theposterior wing of the first longitudinal segment includes at least twolocking holes.
 9. The fusion implant system as set forth in claim 1wherein each of the posterior tab and the anterior tab of the secondlongitudinal segment include a locking hole.
 10. The fusion implantsystem as set forth in claim 1 wherein the third longitudinal segmentincludes two anterior tabs and two posterior tabs
 11. The fusion implantsystem as set forth in claim 10 wherein each of the anterior tabs andthe posterior tabs of the third longitudinal segment include at leastone locking hole. 12-22. (canceled)
 23. A method of enabling a fusionsurgery comprising providing an fusion implant system comprising a platecapable of attachment to the lateral section of a tibia and comprising arail member having a calcaneal segment including a stirrup having a holethat receives a fusion screw and a first lateral segment that includes aposterior wing, a second lateral segment the includes a central lockinghole and an anterior tab and a posterior tab, and a third lateralsegment that has at least one locking hole and at least one posteriortab and at least one anterior tab, and a targeting jig that has a Cshaped body that permits placement of the fusion screw through the holein the stirrup of the calcaneal segment
 24. A method of enabling afusion surgery comprising providing a plate, and a fusion screw having afusion screw head portion, wherein the plate is capable of attachment tothe lateral section of a tibia using bone screws and, and a plateextending along a longitudinal axis and comprising a rail member havinga first segment which is a calcaneal segment including a stirrup thathas a distal hole that receives the fusion screw and cooperates with thefusion screw head portion to hold the plate relative to a calcaneus inuse, and the plate having a second segment including at least one holethat cooperates with the bone screw to hold the plate relative to thetibia, and providing a jig that cooperates with the plate to provide forplacement of the fusion screw through the distal hole to encouragefusion between the tibia, and a talus, and a calcaneus.
 25. A method ofenabling a fusion surgery as set forth in claim 24 further including asecond fusion screw and wherein the jig has an attachment for theplacement of the second fusion screw to avoid impingement with the firstfusion screw and the bone screws. 26-39. (canceled)